						<fieldset>
							<div class="separatore"></div>
							
							<h4>compila il form</h4>
							
							<p>
							<label>nome*</label>
							<input type="text" class="text" name="name" id="name" value="<?php echo isset($_POST["name"]) ? $_POST["name"] : "" ?>"/>
							</p>

							<p class="secondo">
							<label>cognome*</label>
							<input type="text" class="text" name="surname" id="surname" value="<?php echo isset($_POST["surname"]) ? $_POST["surname"] : "" ?>"/>
							</p>

							<p>
							<label>email*</label>
							<input type="text" class="text" name="email" id="email" value="<?php echo isset($_POST["email"]) ? $_POST["email"] : "" ?>"/>
							</p>

							<p class="secondo">
							<label>telefono</label>
							<input type="text" class="text" name="phone" id="phone" value="<?php echo isset($_POST["phone"]) ? $_POST["phone"] : "" ?>"/>
							</p>
														
							<p class="area">
								<label>messaggio*</label>
								<textarea class="textarea" name="report" id="report"/><?php echo isset($_POST["report"]) ? $_POST["report"] : "" ?></textarea>
							</p>

							<div class="pulizia"></div>
							<p class="note">i campi contrassegnati da (*) sono obbligatori</pre>

							<div class="separatore"></div>
							
							<h4>inserire codice di sicurezza</h4>

							<p class="captcha">{imageverification}</p>
							
							<div class="pulizia"></div>
							<div class="separatore"></div>
							
							<h4>normativa sulla privacy</h4>

							<p class="area">
								<textarea class="textarea"/>{loadposition privacy}</textarea>
							</p>

							<p class="accetto">
								<strong>accetto</strong>
								<input type="radio" name="agree" id="agree-valid" value="1"/> <label for="agree-valid">s&igrave; </label>
								<input type="radio" name="agree" id="agree-invalid" value="0"/> <label for="agree-invalid">no</label>
							</p>

							<p class="secondo">
								<button type="submit">invia</button>
							</p>
														
						</fieldset>